WHEN TO START SOLID FOODS

Health Canada, the Canadian Pediatric Society, the American Academy of Pediatrics (AAP), IBFAN, UNICEF, the WHO Global Strategies on Infant Feeding, and most paediatric societies around the world recommend exclusive breastfeeding to about six months.

With the exception of the American Academy of Pediatrics, all these groups recommend continued breastfeeding after 6 months to two years and beyond.  The AAP recommends exclusive breastfeeding to 6 months and continued breastfeeding to at least 1 year and then for as long as the mother and baby desire. Why they did this change is beyond us.

The best age at which to start the baby on solids is when he or she shows signs of interest and readiness – this is often around 6 months, but sometimes it’s a little bit earlier or a little bit later.  Follow your baby’s cues instead of the calendar. By five or six months of age, most babies will be trying to grab food from your plate.  When the baby is starting to reach for food, grabs it and tries to put it into his or her mouth, this seems a reasonable time to start letting him or her eat.

WHY START SOLID FOODS?

1. There comes a time when breastmilk no longer supplies all your baby’s nutritional needs, iron being really the only such need. A full term baby will start requiring iron from other sources by 6 to 9 months of age. This is seen as a problem with breastmilk, but it is not a problem.

There is an important protective advantage for the baby that iron concentration is kept low in breastmilk. Iron is required by many bacteria that cause infection in humans and the large amounts of iron (as is added to infant formulas), put the baby at risk of infection by these bacteria if they are fed lots of iron. See this article.

The developing baby in the womb receives iron from the mother, and at birth receives a “blood transfusion” through the umbilical cord. There is some iron in breastmilk, but not a lot, kept low for the reason mentioned above.

When the baby is about 6 months old, the baby’s immunity has developed to the point that he can fight off the bacteria that might develop in his/her intestinal tract. Even then, the complex immunity of breastfeeding continues to protect the baby, but now, with the addition of iron containing food, the baby’s risks of infection are much diminished.

As a trainee in pediatrics, I can remember two toddlers, about a year old who were breastfeeding exclusively. They refused to eat food. They were thin, no question about it, but they were not iron deficient and not anemic, interestingly. I do not really have an explanation for this, but it is possible to explain why they would not eat food. For an explanation, see this blog on food. Near the end of the blog, you will find a discussion of ketosis which explains their refusing to eat even though they were not getting much in the way of calories.

2. Some babies, amazingly, can continue to grow well on breastfeeding alone well past a year. But just because they can grow well on breastfeeding alone is not a reason to delay introduction of solids if the baby is obviously ready for them.

3. Starting solids is a developmental milestone. The baby is growing up and becoming ready to participate with the rest of the family in this activity.

SOLIDS WHEN THE BABY IS NOT GETTING ENOUGH AT THE BREAST

When a baby seems to be hungry and/or weight gain is not continuing at the recommended rate it may be reasonable to start solids as early as four months of age and perhaps even 3 months. Consider solids only after you have done everything possible to improve the breastfeeding so that the baby gets more breastmilk.  See the information sheets “Late Onset Decreased Milk Supply or Flow” and “Protocol to Increase Breastmilk Intake”.

There is no need to be shocked. Until about 20 years ago, it was usual (and it still is) for some pediatricians to recommend starting solids at 4 to 6 months and often that meant 4 months because they pediatricians were not confident about breastmilk being good enough for longer (or formula for that matter).

In fact, some pediatricians in the early years of the 20^th century were recommending food to supplement milk of any sort by 2 or 3 weeks after birth.

Giving breastmilk in a bottle is not recommended in these situations because the baby who is not satisfied completely at the breast may start to take more and more from the bottle, and end up refusing to take the breast completely.  There is also no advantage to starting infant formula – if the baby is able to eat solids, they are a much better choice!

If the baby has been supplemented with infant formula from earlier on in his or her life, the supplement can be gradually replaced with solids starting around 4 months or evn 3 months of age. Formula can even be mixed into solid foods to reduce the need for bottles and/or lactation aids.

Note: Starting solids at four months of age when baby is exclusively breastfed and things are going well, is not recommended.

HOW SHOULD SOLIDS BE INTRODUCED?

Around 6 months of age:

• What foods you start with and in what order they are introduced does not really matter. Rules have been made up to drive parents crazy. The only foods to avoid are very spicy foods, foods easy to choke on (like whole grapes, popcorn), and honey/foods that contain honey (until after 1 year of age) because of the risk of infant botulism. Your baby will be able to eat most of the foods your family eats, with some adjustments to the texture, right from the start. There is no need for foods to be pureed – simple mashing with a fork is all that is fine, though not really necessary, at first.

• Commercially prepared baby foods, including infant cereals, are not required. They are expensive for what you get, are poor in nutrients except iron most of which ends up in the diaper and are constipating.

• Other beverages are not required if the baby is still drinking a significant amount of breastmilk. A small amount of water in an open cup can be offered or mixed with solids, if desired. Please avoid highly sugared beverages such as fruit juices and there is no need for so-called “soft drinks” such as colas. In fact, they are harmful, being full of sugar.

• Offer solids in a relaxed way when you are eating/when the family is eating.

• Allow your baby to eat whatever s/he wants from what you have offered. There is no need to control the amount of solids nor to force the baby to “finish” – let the baby eat as much or as little as he or she wants. At 6 months or a year or even older, the baby does not need to eat more because, though sad, children are starving somewhere in the world.

• The easiest way to give iron to your baby is by giving him or her meat poultry or fish. Infant cereal has iron, but it is poorly absorbed iron and may cause the baby to be constipated. If you wish your baby to be vegetarian, foods that contain iron is available on the internet. Just put “foods for babies that contain iron” in the browser and you will find lots of information. Yes, the first foods mentioned are likely to be meat, chicken and fish,, and, unfortunately, sometimes even iron fortified cereals, but after that there is still a long list of foods containing goodly amounts of iron.

• Respect your baby’s likes and dislikes. If your baby does not like a certain food, do not try to force him or her to eat it – just try again another time.  Sometimes babies need to be offered a new food a number of times over a period of days or weeks before accepting it. If your baby still won’t eat a particular food, it’s ok!  There is no essential food (except breastmilk).

If, for some reason, you are going to start your baby of food around 4 months of age:

• Start with soft and easily mashed foods, like ripe avocado or cooked sweet potato, mashed banana or any food easily mashed.

• Sometimes the baby will eat more easily off your finger than off a spoon.

• Follow your baby’s cues. As the baby tolerates solids, both quantity and variety of foods can be increased, as the baby desires.

SOLIDS OR BREAST FIRST?

If breastfeeding and the introduction of solid foods both are going well, it probably does not matter much. Most babies let their mothers know that they want the breast, so the choice is obvious. If the baby is reluctant to eat food after a breastfeed, there is nothing wrong with that.

If your baby tends to be fussy at the breast, sometimes offering some solids before the breast can be helpful. However, fussiness at the breast may signal late onset decreasing milk supply and flow.

Get help if the baby is consistently refusing solids after 6 months. See also Ketosis at the end of this article.

The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.

This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!

©IBC, updated November 2016, 2021

Questions or concerns?  Email Dr. Jack Newman (read the page carefully, and answer the listed questions).

Make an appointment at the Newman Breastfeeding Clinic.